The University of Kansas Medical Center Division of Information Resources Department of Telecommunications & Networking Cell Phone/Data Plan Request Form 1. The Department of Information Resources is responsible for managing all cellular phone/data contracts between the University of Kansas Medical Center and cellular providers regardless of the funding source. This policy includes data enabled devices including BlackBerry‟s, PDA‟s and other mobile devices. 2. We are required, by an Executive Order of the Governor, to assure that the cellular/data plan selected for your use is the minimum plan necessary to meet your business requirement. We will work with you to understand your business need and to identify the appropriate plan. Please summarize, in the space provided below, your rationale for requiring cellular service. 3. State policy prohibits more than minimal personal use of a State-provided cellular phone. A detailed listing of your calls (call log) will be provided to you each month from the Division of Information Resources. You will need to review the calls and certify that they are all business related. In the event some calls are not business related you will need to identify the calls on the call log. Note: IRS regulations will require the University to report the value of the personal usage as a taxable benefit. 4. If your bill is for the base plan only, we will report as taxable income the pro-rated value of the personal use as a percentage of the base plan charge. For example, if your base plan is $40 and 10% of the use is personal, we will report taxable income of $4. If your bill is in excess of the base plan, we will report as taxable income the pro- rated value of the personal use (included in the base plan) as a percentage of the base plan charge. Additionally, you will need to reimburse us for any personal use charged beyond the base plan. Your department will have 15 days following the receipt of the monthly call log to process the reimbursement. 5. Cellular contracts cannot include charges for replacement or repair of a lost or damaged phone/data device (“insurance”), or any other added services (“roadside assistance”). 6. No reimbursement can be offered for business-related use of a personal cell phone. 7. The State Division of Accounts and Reports will periodically audit usage logs. (Signature/Approval required on next page.) I have read, and agree to, items 1-7 above. (Must initial each line below) _____ I understand that this device is to be use for business only. _____ I understand that any unreimbursed personal calls will appear as taxable income on my pay check. _____ I understand that all calls are reviewable under the „Open Records Act‟. http://www.kumc.edu/Pulse/policy/KSOpenRecordsAct.html http://www.ksrevenue.org/pdf/kora.pdf ________________________________ Signature ________________________________ Name (printed) ________________________________ Date _____________________________ Budget Number ________________________________ Cell Phone Number (if existing) ________________________________ Current/Preferred Vendor ________________________________ Type of Device Requested Cell Phone/Mobile Device/BlackBerry etc. Rationale for cellular/data service. Please indicate the business case for the University funded device: IR Use Only: Request Approved Request Denied The University of Kansas Medical Center Division of Information Resources Department of Telecommunications & Networking Cell Phone/Data Device Disposition At your department‟s discretion you may have the option of purchasing the cell phone or data device and taking it with you when you leave the University. You will need to reimburse the University for the value of the device based on a 3-year useful life. (I.E. You leave the University 2 years after the original purchase of the device. You will need to reimburse the University for 1/3 of the original cost of the device.) At your department‟s discretion the phone number may be ported to your personal cell phone device/carrier if the department no longer needs the number. As soon as possible after announcing your resignation you will need to inform your department that you wish to purchase the device or port the number and obtain their approval. Upon approval telecommunications will work with you to port the number to your designated carrier. If you do not wish to purchase the device it will remain the property of your department.